New Patient Medical History Questionnaire
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1
2Medical History Questionnaire
New Patient
Patient Name:____________________________________________________________________ Date:_______________________
Date of Birth:_____________ Date of Last Eye Exam:______________ With Doctor:________________________________________
List or use our patient medication log below to provide a list of any medications you currently take (Prescription and Over-the-
Counter):____________________________________________________________________________________________________
Do you have any allergies to any medications?
No
Yes If yes, please check all that apply:
Penicillin (PCN)
Sulfa
Barbiturates
Insulin
Iodine or Contrast Dyes
Aspirin, Ibuprofen & Naproxen
Novocain, Lidocaine, Epinephrine
General Anesthesia
Anti-Seizure Medications
Pain Medication (Codeine, Vicodin,
Celebrex, Vioxx, Lortab, etc.)
Other: ___________________________________________________________________________
List all major illnesses (glaucoma, diabetes, high blood pressure, heart attack, etc.) or injuries (concussion, etc.):
____________________________________________________________________________________________________________
List any surgeries you have had (cataract, appendectomy, etc):
____________________________________________________________________________________________________________
Please indicate by checking any problems in the following areas that you have and provide brief detail in the blank provided
(“unmarked” problem areas indicate you do not have any related health issue).
Eyes (poor vision, eye pain, tearing, redness, dryness, etc.)
____________________________
Eye Disease (
Cataract, Glaucoma, Macular Degeneration, Corneal, etc.)
_______________________________
General / Constitutional (fever, heat stroke, weight loss, weight gain)
_______________________________
Ears, Nose, Throat
, dry mouth)
(hard of hearing, stuffy nose, earache, cough
_______________________________
Cardiovascular (high BP, racing pulse, etc.)
_______________________________
Respiratory (congestion, wheezing, short of breath, etc.)
_______________________________
Gastrointestinal (stomach upset, diarrhea, ulcer, constipation, hernia)
_______________________________
Genital, Kidney, Bladder
(painful or frequent urination, impotence, yellow jaundice, etc.)
_______________________________
Females – Are you pregnant? Nursing?
_______________________________
Muscles, Bones, Joints (joint pain, stiffness, cramps, swelling, arthritis)
_______________________________
Skin (pimples, warts, growths, rash, etc.)
_______________________________
Neurological (numbness, headache, seizures, paralysis, etc.)
_______________________________
Psychiatric (anxiety, depression, insomnia)
_______________________________
Endocrine (diabetes, hypothyroid, etc.)
_______________________________
Blood / Lymph
(bleeding, cholestolemia, anemia, problems related to blood transfusion, etc.)
_______________________________
Allergic / Immunologic (sneezing, swelling, hives, redness, itching)
_______________________________
STD (HIV, AIDS, Herpes, etc.)
_______________________________
Family History (Mother, Father, Grandparent, Sibling)
Has any member of your family had these diseases (mark all that apply)?
No
Yes
Unknown
Blindness
Cataract
Glaucoma
Diabetes
Hypertension
Heart Disease
Stroke
Cancer
Thyroid Disease
Arthritis
Other heritable disease:_____________________________________________________________
Social History
Occupation:__________________________________________________________________________________________________
Have you ever had a blood transfusion?
No
Yes
Do you drink alcohol?
No
Yes If yes, how much?____________ Do you smoke?
No
Yes If yes, how much?____________
Do you use drugs / medications not prescribed by a doctor?
No
Yes If yes, what? And how often?________________________
Does your vision limit any activities of daily living (driving, reading, sports, work, etc.)?
No
Yes
Do you currently wear glasses?
No
Yes Do you currently wear contacts?
No
Yes
Have you ever had refractive surgery (LASIK, PRK, RK, IOL Implant, etc.)?
No
Yes If yes, what and when? ______________
If not, would you be interested in refractive surgery?
No
Yes
Form 1 Revised: 01/04/2012
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